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General Excellence 

Groundbreaking programs at San Francisco General Hospital may well change the way the entire U.S. health care system deals with domestic violence. To understand why, you have to understand Dr. Beth Kaplan.

Wednesday, Apr 18 2001

Page 2 of 4

But what affected her as much as anything that night, she says, happened an hour or so later, in the emergency room. "I was sure the doctor would just treat her injuries and send her on her way, but he didn't," Kaplan says, remembering how the doctor talked to her friend about her relationship, explained to her that other people were going through the same thing, and even helped lay out legal options. He also urged her to change the locks on her doors.

"It was ...," as Kaplan recalls, "amazing."

Kaplan spent two years at Boston City Hospital; they nourished both her passion for women's health issues and her reputation in the field. They also wore her down, because she spent her time in Boston chaotically balancing two full-time jobs: acting as the emergency room's chief resident (that is, its supervising physician); and conducting what turned out to be significant research on ectopic pregnancy, which occurs when an embryo begins growing in one of a woman's fallopian tubes, rather than in her uterus. Kaplan established a correlation between the often fatal condition and the prenatal symptoms of abdominal pain and bleeding. Her research almost certainly saved lives, and almost seemed to imperil her own.

"Beth is probably the only person I've ever known who did groundbreaking research while being chief resident," recalls Yale University emergency medicine professor Gail D'onofrio, who supervised Kaplan in Boston. "It almost killed her in the process, though. She was down all the time, pulling her hair out, talking about how she couldn't do it. But she did it."

Kaplan survived Boston, and in 1993 she accepted an offer to become an attending physician in the emergency room at S.F. General. "The General" was -- and is -- ground zero for the medical fallout from urban blight in San Francisco. Its status as the city's largest public hospital means it serves a population that is primarily uninsured and poor, and therefore prone to drug use, violence, and other social ills. As the city's primary trauma center, S.F. General receives more violence victims than any other local hospital. And its Inner Mission location, in close proximity to gang activity and public housing, brings the hospital windfalls of local trauma traffic as well. For Kaplan, who had been interested in urban medicine since her days at Baltimore's trauma center, The General felt like home.

Like any major trauma center, it was flooded with domestic violence victims. While most of them would pass through treatment undetected, enough cases were apparent that emergency room workers began to take notice. "Back then, we really weren't doing anything about it," Kaplan recalls. "We were writing names in a book and not following up at all. There was lots of concern about the issue, but no real sense of what we could do about it."

Kaplan's arrival at S.F. General roughly coincided with the launching of a pilot program by the San Francisco-based Domestic Violence Prevention Fund. The Fund, a prominent national nonprofit organization based in Potrero Hill, only a quick walk from S.F. General, was seeking 12 hospitals -- half in California, half in Pennsylvania -- that would agree to teach most of their emergency room staffs -- from doctors to janitors -- how to identify domestic violence victims, and then how to direct those victims to shelters and other aid. Kaplan and a few other hospital staffers got word of the search and began to lobby.

"There was definitely begging and pleading involved," she says.

In the end, the lobbying succeeded. The proximity of S.F. General to the Fund's office and the high-risk population serviced by the hospital's emergency room made it an ideal candidate. By the end of 1994, training was under way. Kaplan was in charge, and the timing was ideal. The media spectacle of O.J. Simpson's murder trial was in full swing, and his history of violence against his wife, Nicole Brown-Simpson, was inescapable. The entire country had heard the anguished 911 calls and seen the pictures of her after she'd been beaten. And even though the jury found Simpson innocent, the entire country saw how it ended for Nicole.

"I think people were able to personalize the issue for the first time," Kaplan says. "Suddenly, it's a real problem, not just an idea. ... Also, it showed everybody that the ultimate outcome of domestic violence is often lethal. And, from a medical perspective, we're always trying to prevent lethal outcomes. So it made [promoting awareness] a little easier."

Still, the transition was far from smooth. Nurse Lettie Muller, 51, who has been in the S.F. General emergency room for nine years, remembers Kaplan absorbing her share of sarcasm and rolled eyes while she urged doctors, nurses, and paramedics to make a habit of screening for violence. "She was asking a very busy place to do a lot of extra stuff," Muller recalls. "So a lot of people questioned why."

Kaplan knew she was being sanctimonious; she chose not to care. "People got so sick of me on my bandstand," she says. "During rounds, I'd always be trying to remind people about screening [for violence]. I knew I was being annoying. That wasn't my concern."

By 1998, screening for histories of partner violence at S.F. General was increasingly routine -- and effective. Whenever possible, hospital staff were trying to screen every woman they saw older than 13, whether she was in for a broken arm or an asthma attack. And staffers were catching two or three people a day with "active" histories of violence that they wouldn't have noticed otherwise. For that, there were accolades: S.F. General's program received an award from the National Association of Public Hospitals for "improving the health care response to domestic violence."

A research effort led by Kaplan and funded by George Soros' Open Society Fund showed that 13 to 14 percent of all women and gay men being treated at The General were either currently experiencing domestic violence or had experienced it within the past year. As part of that research, once abuse was documented, nurses "intervened" with patients; that is, they explained to the patients that they were victims of illegal activity, that domestic violence is a widespread phenomenon, and that resources were available for domestic violence victims.

About The Author

Jeremy Mullman


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